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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 019200720
Report Date: 07/22/2022
Date Signed: 07/22/2022 11:12:36 AM

Document Has Been Signed on 07/22/2022 11:12 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME:ELWYN CALIFORNIA - TRAVISOFACILITY NUMBER:
019200720
ADMINISTRATOR:TEKLE, SOPHIAFACILITY TYPE:
734
ADDRESS:722 TRAVISO CIRTELEPHONE:
(925) 292-5742
CITY:LIVERMORESTATE: CAZIP CODE:
94550
CAPACITY: 4CENSUS: 3DATE:
07/22/2022
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
08:35 AM
MET WITH:Sophia Tekle, AdministratorTIME COMPLETED:
11:25 AM
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On 7/22/2022 at 8:35AM, Licensing Program Analyst (LPA) G. Luk arrived unannounced to conduct a case management visit in regards to death report received on 7/14/2022. LPA met with Administrator, Sophia Tekle and explained the purpose of the visit.

LPA received death report on 7/14/2022 for client (C1). Death report revealed that C1 passed away at the hospital on 7/14/2022 due to urinary sepsis.

LPA interviewed 1 staff and obtained documents including C1's physician's report, MAR, communication with doctor, and care notes.

LPA may return on a later date.

Exit interview conducted. A copy of this report provided.
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Grace Luk
LICENSING EVALUATOR SIGNATURE: DATE: 07/22/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/22/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
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